Home Insurance Form Customer Details First Name Last Name Birthday Street Address City Province OntarioAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaPrince Edward IslandQuebecSaskatchewan Postal Code Phone Number Email Address Is your spouse on title? YesNo Home Details Building Type DetachedSemi-detachedTownhouseApartmentCondominium What year was your home built? When will the home be occupied? Square footage of the home? Number of Bathrooms? 11.522.533.544.55 Is there a finished basement? YesNo Is the basement being rented? YesNo If yes, what is the rental income? Do you currently have insurance? YesNo Any claims in the last 5 years? YesNo Any cancellations for non-payment in the last 3 years? YesNo Does your home have security cameras? YesNo Is your home monitored by a security company? YesNo Do you have a swimming pool? YesNo Last Updated Systems Electrical – Year Last Updated Plumbing – Year Last Updated Roofing – Year Last Updated Heating – Year Last Updated Provide any specific requests or concerns Home Insurance Meet Us & We Can Help You Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut elit tellus. Name Last Name Is your spouse on title? YES NO City Phone Birthday Postal Code Email Province Ontario Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Prince Edward Island Quebec Street Address Send jason@bespokeinsurance.ca 416-930-4348 494 McNicoll Avenue, Suite 200 Toronto, ON M2H 2E1